Thurman: Health diplomacy must overcome religious and cultural barriers

Sandra Thurman, president and CEO of the International AIDS Trust, answers questions after her lecture at the Amphitheater Tuesday. Thurman, a former director of the Office of National AIDS Policy, has advocated the fight against AIDS for more than 20 years. Photo by Ellie Haugsby.

Nick Glunt | Staff Writer

Tuesday’s lecturer Sandra Thurman, president and CEO of the International AIDS Trust, quoted Martin Luther King Jr. to convey her views on global health diplomacy: “We must learn to live together as brothers or perish together as fools.”

The International AIDS Trust is a non-governmental organization that focuses resources to aid the worldwide battle against AIDS. The organization must overcome cultural and religious barriers abroad to take preventative action.

Thurman served as the director of the Office of National AIDS Policy under former President Bill Clinton and has been a leading advocate in the struggle against AIDS for two decades. She was the second speaker for Week One’s topic on “Global Health and Development as Foreign Policy.”

The U.S. Global AIDS program started forming in 1997 under the Clinton administration, Thurman said. The main problem at the beginning was that therapies to combat AIDS were very expensive and complicated
in use.

“There was a lot of doubt whether, No. 1, we could afford to treat people in the developing world,” Thurman said, “and No. 2, whether we could actually do it.”

She credited people like Monday’s speaker Paul Farmer, one of the founders of Partners In Health, in proving that treating underdeveloped countries is entirely possible. She said that oftentimes, people in those less fortunate countries are more willing to accept treatment than those in the developed world.

Though the phrase “health diplomacy” has only recently taken hold, Thurman said people like Farmer have been practicing it for decades. It is now an emerging field of practice in today’s world.

“Health diplomacy,” Thurman said, “provides an opportunity to both proactively and systematically provide interdisciplinary training of health and development professionals and diplomats to dramatically improve the delivery of health care services, development assistance and scientific research.”

Global health as diplomacy

Thurman said that in addition to simply lending aid to those countries, such treatment has created peace in situations of war or unrest.

“The fundamental importance and power of the provision of health services has stabilized situations where politics, frankly, has failed miserably,” she said.

Assistance to health and development can act as the initial steps to “building bridges” between nations, quelling human suffering and creating peace, Thurman said. She posed the worldwide eradication of smallpox in the 1960s, when it was believed that between 80 and 100 percent of the global population needed to be immunized, as an example of such diplomatic action.

Thurman mentioned innovations made by Jim Grant, head of UNICEF from 1980 to 1995, as inspiration for the coming years. Grant sparked a “revolution” to increase child immunizations in developing countries to 80 percent, resulting in 100 million immunizations in China in two day’s time in 1993.

Under former President Jimmy Carter, Grant also discovered that the U.S. could negotiate ceasefires in warring nations like Sudan to provide health care
to children.

“Those people in those countries actually care about their children and families just like all the rest of us do,” Thurman said. “They were willing to find a way to lay down their guns and arms for a number of weeks so that teams from all over the world could come in and actually care for their children.”

Thurman said this is an important lesson. Children are, as she calls them, “the Trojan horse of public health.”

By focusing efforts on the children of the world, people are much more willing to comply with health care efforts.

Facing roadblocks

Thurman said religious and cultural barriers can be detrimental to the development of proper health care practices in these countries.

Sexual behavior is perhaps the most prevalent of these barriers, she said. Misusing or disusing condoms, having multiple sex partners and not being circumcised are some specific practices that increase the spread of AIDS.

To encourage preventative measures, speaking with religious leaders is key, Thurman said; however, she fears it will never fly in some places like Kenya, Tanzania and Uganda, where openly gay men have been murdered by conservative religious sects.

Even in America, there are situations where religion has blocked preventative actions against AIDS. Thurman recalled one particular event at which she bought condoms for the Atlanta-based Sisters of Mercy because they couldn’t let condoms show up in the records. They bought her office supplies in exchange.

She said this is an excellent example of diplomacy “finding ways over
and under.”

To solve issues in developing countries, Thurman said undergraduate and graduate degrees are now regularly combining public health with diplomacy, theology, law, business and development. To influence change, professionals need to have the tools to understand the religion and culture in the places they will work.

“The new cadre of students entering health science training institutions today are going to be the leaders of this work tomorrow,” she said. “We need to make sure we’re giving them the knowledge, support and training that they need to be effective.”

Looking to the future

Thurman said it is necessary to utilize clear, deliberate and thoughtful engagement to solve the grip of AIDS and other infectious diseases.

“All of these kinds of activities require leadership, creativity, maybe a little bit of deceit and investment at the highest levels of politics, academia and the private sector,” Thurman said, “to maximize our efforts on the ground and the fight against diseases all around the world.”

Q: Can you talk a little bit about the coordination among all of the players in this realm? When you think about now, when you have major foundations coming into the game, a number of different countries and agencies that have been doing this work for a long time, how do you all pull together, understand what everybody is up to, and be most effective as a coordinated group?

A: I think it would probably be easier to describe ways that we don’t get along than we do get along. But the fact of the matter is that this is a place where, I think, UN structures actually work. It provides a framework for us to share information as nations and individual agencies in a way that no other framework actually gives us the capacity to do. I think we’re doing better. There’s a current initiative inside the State Department, which has been championed by Secretary of State Hillary Clinton, called the Global Health Initiative, that is making an effort to pull together all of the global health programs inside the U.S. government. This includes the Department of Defense, obviously USAID, CDC, the President’s Emergency Plan for AIDS Relief and others. Although it’s a real challenge to do that, Secretary Clinton has hired a very strong-willed woman — who was from the private sector in health care — who is doing a really good job of cracking the whip and carrying a chair. She might need some other weapon before it’s all over, but she’s doing an extraordinary job of beginning to find ways that we can pull together our U.S. government partners. The wonderful thing that has happened with the growth of the Gates Foundation, as others, is that they have a convening power that almost no one else does. They’re seen as objective, for the most part, partners in this work. They’re funders outside government, so they actually do fund a lot of the same programs that these government agencies fund. They’ve played an important role, and I think almost a moral authority, for those agencies and seem to be doing a good job of calling them to task. We still have a lot of work to do, but I think we’re doing better. UN seems to be the best structure for that to happen.

Q: Is there an inverse relationship between private philanthropy, global health care dollars and government responsibility? Are we simply shifting responsibility from the government to the private sector?

A: I think that, and my hope would be, is that we’re not trying to shift responsibility from the government sector to the private sector. Although in these fiscal times, it’s going to be very difficult for us to maintain our current levels of spending in global health and certainly to get increases in certain areas in global health, what I think is happening is that with the commitment of the Gates Foundation — and again, many others — what we’re seeing is increased pressure on government to actually continue to invest and shift some of their investments to global health from other programs. I think that’s very important, because these donors — both in the non-governmental organizations and in the big foundations — have a tremendous amount of political clout. They’re using that to keep pressure on the government to invest in global health and not so much in defense and other activities. I think they’re playing an important part.

Q: I have two questions in the few I’ve seen so far that go to the issue of the anti-vaccine, anti-immunization movement and what effect it is having.

A: It has had a tremendous effect. Part of our challenge in Nigeria, around polio immunization, was related to the myths that have evolved in this country about vaccination: That vaccination was going to make their children sick, or poison them, or all of these kinds of myths that are floating around. It hasn’t had a huge effect yet in global health, but I’m really concerned about the impact that it’s having domestically, where we see dramatically declining rates of immunization in our children. Of course, the good news is that in most school systems, you can’t put your kids in public school — and I would imagine most private schools; our kids went to public school— without having a certificate of immunization. I think there’s a push back against that, but it’s a place where we need a tremendous amount of education. You’ve seen this happen in AIDS. We forget that we have to continue to educate people, over and over again, as new generations marry and have families and children. We need to make sure that we’re continuing to educate people, even if we make the assumption that people have information already. I think it’s, a tad bit, our own failure in that regard. Aside from some of the myths that we saw around polio immunization, I think that we are doing better, but it is an issue.

Q: Let me follow up with this question that goes to religious and cultural barriers that you encounter. How do you solve them without offending or making enemies of the people you’re trying to help?

A: Well, that’s hard, and I’m not sure that we’re always successful in doing that, but I think it’s part of the reason that it’s so critical that we educate our practitioners, either in diplomacy or public health, in the cultures and religions in which they’re working. We’ve seen this in Kenya; we’ve seen it all over Africa: issues relative to sexual behavior, the use of condoms, multiple partners, sexual practices that put people more at risk. Circumcision is a big issue, more tribal than religious in Africa, but there is a big push to circumcise men in some areas because it reduces the rate of infection in those populations by as much as 30 percent. But adult circumcision is no easy matter, so we’ve had to do a lot of work in educating people. I think we’re making some progress. Engaging religious leaders upfront in conversations about these issues is really important. But, there are some places where I think we’re never going to make headway. We’ve seen that, of late, in Uganda, Kenya and Tanzania, where openly gay men have been murdered as sort of a religious act. Both Muslims and Christians in those communities — very conservative Muslims and Christians — have been a part of that violence. I think there are some places we’re going to have to understand that we aren’t going to make great inroads, but those are the fringes on either side. I think we have a good chance — in conversation, dialog and partnership — of finding ways around these issues. One case in point that I experienced early in my career was working with the Sisters of Mercy in Atlanta. We have Sisters of Mercy doing the same thing in other parts of the world, and I won’t name it because I’m sure their bishops will be cranky. I found a way to help the Sisters of Mercy buy condoms when I was Executive Director of AID Atlanta. They obviously couldn’t put that on the books, but they were serving the homeless and the poor. I bought all the condoms, and they purchased all of my “office supplies.” Again, it’s all about the diplomacy: You have to find ways over and under; that’s what diplomacy is. They would come down in their little white van, with their little red cross on the side, and offload all of their pencils. I’m sure that people who were running the Mercy health care must have wondered what in the world they were doing with all of those tablets, pens and erasers. Nonetheless, they were getting their condoms. They still may be doing that to this day — I’ve been gone awhile. Anyway, I think there are ways we can find common ground.

Q: Let me ask these two questions together. Should we be attacking one disease at a time? The questioner said, “I’m hopeful we can provide comprehensive care.” And where do you see the U.S. playing a role in combating chronic disease abroad, infectious diseases and everything?

A: It’s absolutely true. A couple of things: I think that we can, absolutely, look at treating diseases and preventing diseases across the board. We’ve actually now used our platform of the President’s Emergency Plan for AIDS Relief to expand to reproductive health services, to maternal and child’s health, to immunizations, to other service prevention of mother-to-child transmission of AIDS, from mothers to babies. We’ve used the platform we have built to combat AIDS to now expand to provide other health services. We actually did some of that back in old immunization days, too — built some health care capacity on top of that. But this is the biggest effort we’ve ever had. We are now building out those programs to address other diseases, and that’s part of what the global health initiative, inside of the State Department, is trying to actually do. I think that’s important. The other thing is that we really do have to look at chronic disease. At the end of the day, chronic disease is killing more people than other diseases are. Both here and abroad, we need to be building on existing platforms to address diseases like heart disease, diabetes, cervical cancer, which we’re actually now doing in conjunction with some of our AIDS programs. We’re moving in that direction. But until we slow down these killers that we know we can actually stop, or at least reduce dramatically with relatively few dollars, we need to do that. The fact of the matter is that chronic diseases are a lot more complicated and expensive to treat than engaging in prevention, if we know we can actually stop a disease from happening. Dr. Foege used to say, “No one ever comes up to you and thanks you for preventing the disease that they never got.” It’s a difficult challenge.

Q: What role are the drug and medical supply industries playing in your work?

A: Actually, they have played a major role in this work. We’re actually at a point where drug companies have dramatically reduced the cost of drugs to people in this country, and more importantly, to people in the developing world. We had negotiations with drug companies, through the World Trade Organization and others, about a decade ago, to actually allow us to buy drugs for delivery in Africa that were generic, made in other countries, and not off-patent. That was a huge success. You know, they don’t like to budge on those issues. Medical manufacturers of test kits and other devices have dramatically reduced their cost. Many of them are making very large donations of their goods to clinics, both U.S.-funded clinics and non-profit clinics all over Africa. It took them awhile to step up to the plate, in my personal opinion. I apologize to any drug executives who are in the audience. My personal opinion is we can still do more. We’re looking at the bottom line of those companies and they’re still functioning, making great profits in the billions. I think it would be nice if they would share a little bit of that, but they’ve been very good in recent years in stepping up to the plate.

Q: A couple of questions go to economic equalities and the relationship between the work and the benefit of improving peoples’ health when their economic situation remains less than satisfactory.

A: It’s interesting. It’s a challenge. People’s health becomes a chicken-and-egg situation. If people are suffering from chronic disease or infectious diseases, they can’t work, the children can’t go to school, the parents can’t work on the farm, they can’t send the children to school if they have no income, the children end up falling farther behind, girls wind up engaging in transitional sex, being sold or being abused because they don’t have any income. It’s a very vicious cycle. So at some point in time, I think we have to take a dual strategy. We have to look at providing economic development, support as part of a public health strategy, but that’s long-term, because the majority of the people in the world, as we know, are very poor. It’s a dual strategy; it’s not an either-or proposition. We have to do this hand-in-hand. But if people are sick — or if they have AIDS, or if children’s parents have died of AIDS and they’re caring for four siblings of their own when they’re 12 years old — if we can’t do something to at least keep them healthy, we won’t be able to get very far. If we can keep them healthy, we can at least give them hope. We may not be able to stop poverty at that moment, but if we can keep them healthy, we can at least give them hope that there is a better future. That’s what we’re trying to do, but it’s a delicate balance.

Q: A returning Peace Corps volunteer asks, “Have you involved the Peace Corps in your common-goal efforts?”

A: Absolutely. The Peace Corps is a primary partner of the President’s Emergency Plan for AIDS Relief. We’re now actually educating and training the majority of Peace Corps volunteers, who are working in places hardest hit by the epidemic, in HIV and AIDS activities. Almost every Peace Corps volunteer I’ve meet in Africa is engaged in some kind of HIV and AIDS and other health-related activity, whether it’s mother and child health, neo-natal care, taking care of infants or clean water. They are a major, major player and a very important player because these are folks that are actually living on the ground in community, where those wonderful relationships are developed. These are not people who parachute in — in a suit with goggles or a bag or with this and that — and then, 24 hours later, they’re gone. These are people who live, work and become part of the community. So they are really our best advocates and our best educators.

Q: How have Middle Eastern countries, including Israel, responded to the global health care crisis?

A: It’s interesting; it’s a much more difficult place to work. Obviously, there are resources in many of those countries that are being spent internally on global health issues. Around HIV and AIDS, it’s been very difficult to work in most of those countries because talking about sex, talking with women about reproductive health, even maternal and child health, is a particular challenge in many ways.
But we do see some countries that have done enormously well, like Jordan, which has made maternal and child health and reduction of maternal mortality a priority. That country is really focused on women’s health, which is interesting. But of course, Jordan is not necessarily reflective of some of the other countries in the region. That continues to be a challenge, although many of those countries now have state-of-the-art health care delivery systems. Universities all across the U.S. are partnering with those institutions to expand that delivery capacity. We’re hoping that the situation there will be better.

Q: Can we hear an example of partnership work in a particular country? The questioner suggests AIDS in Uganda.

A: AIDS in Uganda has had some interesting partners. A number of them are actually private partners. Nike has been very involved in girls’ education and girls’ health resource delivery in Uganda. The Nike Foundation is entirely focused on girls’ education and empowerment of girls. They’ve been a wonderful partner.
We have other non-profit organizations like World Vision — a faith-based organization, the largest one in the United States, about a billion dollars a year in services provided overseas. They have been extraordinary partners up in the hardest hit regions in Uganda, where all the child soldiers have been such an issue. They’ve been working up there where many other partners have not been willing to go. And of course, CARE is also in Uganda and in Kenya, doing extraordinary work in partnership there. I haven’t worked in Uganda in the last 10 years as much as Kenya. We have a number of really wonderful private partnerships in Kenya — actually in Uganda, too — with Rotary International. They are doing health clinics and HIV testing days in the same format that we used for national immunization days to get people in, get them tested with volunteers from the community, Rotarians in the community, and then get them connected to some kind of treatment. There are a lot of examples out there of really wonderful partnerships and some real creative ones.

Q: Do you see global health initiatives as including the non-served in this country?

A: Absolutely. I always wonder how we talk about global health and we leave “us” out. That’s probably not a great strategy. The fact of the matter is that we have enormous needs in this country. People in the South, for instance, who are still standing in line and on waiting lists to get AIDS drugs when we’re able to provide them for free in other places in the world. We have to really focus on our own health in the context of global health. These days, it’s a lot easier to do both. The diseases that affect us — again, H1N1, other kinds of influenza that are erupting all over the globe, issues of chronic disease like obesity, heart disease and cancers — affect us all in a very similar way. The way that we invest in research is having global impact. The way that we look at providing comprehensive care, engaging communities in care, looking at faith-based organizations to deliver care — a variety of creative options ought to, more and more, include us in the conversation of global health. I’m tired of “them and us.” We talk about working together and then we immediately engage in a conversation that’s polarized, and we do it over and over again. Doing the same thing over and over again and expecting a different result was, I believe, Einstein’s definition of insanity. I think we might be slightly insane. We’ve got to get with the program.

Q: This is a rather lengthy question, but I think that it is well-framed and very appropriate for our theme this week. Can you comment on the potential pitfalls of framing health assistance as a tool of foreign policy, health diplomacy, particularly the shift in funding for HIV, AIDS and other health assistance programming out of HHS, CDC and USAID, to the State Department, over the last decade or more? Does this shift increase the risk of politics trumping scientific knowledge, and evidence from evaluation, of what works in health and developmental assistance programs?

A: That’s a very good question. I do think that we have to be very careful — and again, that’s sort of my caveat around the language of winning hearts and minds — to focus on some sort of servant leadership, as opposed to other kinds of almost colonialist engagement, in the way that we work with other countries and nations. I do think that there is a risk if we do that, that we have to make really sure that other, outside organizations and entities, certainly universities and other non-profits, are really vigilant in watching what happens in our foreign policy. We need the same kind of advocacy around that that we’ve had in advocacy around HIV and AIDS, generally speaking. I can sort of understand, and of course you know there was a lot of pushback when USAID was merged into the State Department, that they were not happy about it and a lot of people in the development world were not happy about it. But I do think that, at some point in time, we have to have some kind of strategy for engagement that’s comprehensive. If we’re going to move away from this work in silos that we’ve done historically, where you have the Department of Defense working over here, and then four miles down the road you’ve got a big HHS program, and DOD has a clinic over here, and HHS or CDC or somebody has a clinic over here, and then USAID has programs over there — it just creates mass chaos. These poor people really do feel like they’re being invaded. If you’re staying in a country where you have 18 U.S. government agencies working in your country and have no clue to how to get them to coordinate and collaborate, it’s a challenge for them, but it’s an even bigger challenge for us. We can’t articulate what our own people are doing very much. It’s one of the beauties of the President’s Emergency Plan for AIDS Relief. What it’s forced us to do — at least around AIDS at the moment and hopefully, in the long-run, our whole global health response — is to actually sit down and coordinate at the table, not only our own efforts, but the efforts of host countries at the same time. We’re taking their plans, merging them with our plans, and coming up with some sort of common plan that lets us understand and map, with some certainty, the kind of investments and priorities that they have with our own investment and priorities so we’re not falling all over each other.

Transcribed by Lauren Hutchinson